Anti-Tuberculosis Treatment in Renal Impairment

Initial Assessment

The American College of Physicians and Infectious Diseases Society of America recommend calculating actual creatinine clearance using a 24-hour urine collection if the patient has borderline renal function, as serum creatinine alone can be misleading, especially in elderly patients with reduced muscle mass 2, 3
A creatinine of 2.6 mg/dL typically corresponds to CrCl <30 mL/min in most patients, but this must be confirmed 1
Close monitoring is mandatory as TB patients with chronic renal failure have worse clinical outcomes than those without renal failure 4, 5

The Infectious Diseases Society of America recommends no dose adjustment for isoniazid (INH) - use 300 mg once daily or 900 mg three times weekly, as INH is hepatically metabolized and not significantly affected by renal impairment 1, 2, 4
The Centers for Disease Control and Prevention recommend no dose adjustment for rifampin (RIF) - use 600 mg once daily or 600 mg three times weekly, as RIF is hepatically metabolized and conventional dosing can be used 1, 2, 4, 5
The World Health Organization recommends dose adjustment for pyrazinamide (PZA) - use 25-35 mg/kg three times weekly (NOT daily), as PZA metabolites accumulate in renal insufficiency 1, 2, 4, 5
The American Thoracic Society recommends dose adjustment for ethambutol (EMB) - use 20-25 mg/kg three times weekly (NOT daily), as EMB is approximately 80% renally cleared and will accumulate with daily dosing 1, 2, 4, 5

The Infectious Diseases Society of America recommends using levofloxacin 750-1000 mg three times weekly (NOT daily) if CrCl <30 mL/min, as levofloxacin undergoes greater renal clearance than moxifloxacin and requires dose adjustment 1, 4, 6
The Centers for Disease Control and Prevention recommend using moxifloxacin 400 mg once daily even with severe renal impairment, as moxifloxacin undergoes less renal clearance than levofloxacin 1, 2, 4

The American College of Physicians and Infectious Diseases Society of America strongly recommend measuring serum drug concentrations to ensure adequate absorption without excessive accumulation and to avoid toxicity, especially for PZA and EMB given their altered pharmacokinetics 1, 2, 4
The National Kidney Foundation recommends giving all anti-TB medications after hemodialysis on dialysis days to prevent premature drug clearance and facilitate directly observed therapy 1, 2, 4, 6
The Infectious Diseases Society of America recommends reviewing all concomitant medications for potential interactions, as patients with end-stage renal disease often take multiple medications that interact with anti-TB drugs 1, 4

The World Health Organization recommends not simply reducing doses, as this lowers peak concentrations and compromises efficacy; instead, extend the dosing interval 2, 7
The American Thoracic Society recommends not assuming normal dosing is safe based on "normal" serum creatinine alone in elderly or low muscle mass patients 6
The Centers for Disease Control and Prevention recommend not giving anti-TB drugs before hemodialysis, as this wastes medication through dialytic clearance 4, 6